CHAPTER 9: H IS FOR HEAD TRAUMA: THE SILENT EPIDEMIC THAT UNDERLIES MANY MENTAL ILLNESSES

After at least five concussions, SPECT and hyperbaric oxygen therapy helped my brain get back to normal.

HALL-OF-FAME NFL QUARTERBACK JOE NAMATH[304]

GARY

On December 4, 1988, Gary Busey was involved in a near-fatal motorcycle accident, striking his head on a curb. The Academy Award-nominated actor, who had been appearing on screen since 1971, was not wearing a helmet and suffered massive head injuries. Surgeons opened up his scalp, drilled holes through his skull, and scraped the temporal side of his brain. The brain surgery was deemed a success, the scars on his scalp sealed over, and he underwent occupational and speech therapy. Gary thought he was healed, but for 30 years, the traumatic brain injury (TBI) inside his skull went untreated. After the accident, the rising star tumbled into freefall. He suffered explosive outbursts (many of them caught on camera in reality TV shows), was arrested on battery charges, overdosed on cocaine, and went to rehab.

In 2008, he met his future wife, Steffanie Sampson. At first, she found him charismatic. “Sometimes he’s ultimately charming and appears caring,” she said “and then sometimes he’s just in your face like a bull in a china shop. It’s weird.” Over the years, she became so worn out she felt like she couldn’t put up with his erratic behavior anymore and threatened to leave if he didn’t do something about it. In order to save his relationship, Gary agreed to get help, and that’s when he came to see me. When we scanned his brain, it showed very low activity in parts of the prefrontal cortex (PFC) and temporal lobes —areas involved in judgment, forethought, empathy, impulse control, and anger management. When Gary and Steffanie saw the scans, they were stunned. Gary had thought he had fully recovered from the accident.

In taking Gary’s history, we learned that the motorcycle accident was only one of many things affecting his brain. He likely had attention deficit hyperactivity disorder (ADHD) as a child; he played tackle football in high school and college; he smoked cigars; he abused cocaine and smoked marijuana; and when he had cancer of the sinuses, he had radiation that affected the brain. All of this chipped away at his brain reserve, leading to a breaking point.

Now we’re fixing Gary’s brain (see the chart below). In the first few months of treatment with our BRIGHT MINDS program, he has cut out marijuana, cigars, and sodas. He has increased his water intake; he is eating healthy, organic, nutrient-dense foods; he’s having hyperbaric oxygen therapy (HBOT) treatments and is taking supplements. He’s even lost weight. I’m excited to see how much more of a change it will make in Gary’s life. I know you are not stuck with the brain you have. You can make it better, and Gary and I are proving it.

BRIGHT MINDS	GARY’S RISK FACTORS	INTERVENTIONS
Blood Flow	Low blood flow on SPECT	Exercise, BRIGHT MINDS diet, omega-3 EPA and DHA, ginkgo
Retirement/Aging	Age 75	New learning
Inflammation	High CRP, low Omega-3 Index	BRIGHT MINDS diet
Genetics
Head Trauma	Motorcycle accident, playing tackle football	HBOT, neurofeedback, nutraceuticals
Toxins	Drug use, cigar smoking	Stop using drugs, stop smoking
Mind Storms	Temper flares	Stress management tools
Immunity/Infections	Low vitamin D level	Vitamin D
Neurohormone Issues	Low testosterone	Testosterone replacement
Diabesity	High blood-sugar levels	Eliminate sugar and sodas, BRIGHT MINDS diet, exercise, targeted nutraceuticals
Sleep	Insomnia	Sleep strategies

Gary’s SPECT Scan Before

GARY’S SPECT SCAN BEFORE

Overall low activity, especially to frontal and temporal lobes

As you have seen throughout this book, your brain is at the heart of what makes you who you are. When it works right, you work right; and when it is troubled for whatever reason, you are much more likely to have trouble in your life. Many people think the brain is rubbery and fixed within the skull, but it isn’t. As I’ve taught for decades, your brain is soft, about the consistency of soft butter, tofu, or custard —somewhere between egg whites and gelatin. It floats in cerebrospinal fluid and is housed in a very hard skull that has many sharp bony ridges (see next page). As such, it is easily damaged.

In this chapter, we are focusing on physical trauma to the brain (biological circle). Whiplash, jarring motions (think shaken baby syndrome), blast injuries, and blows to the head can cause the brain to slosh around, slamming into the hard ridges inside the skull. Here is what happens in the brain after physical trauma:

• Bruising
• Broken blood vessels and bleeding
• Increased pressure
• Lack of oxygen
• Damage to nerve cell connections
• Ripping open of brain cells that spill out proteins like “tau” that cause inflammatory reactions

On top of that, your pituitary gland (which regulates your hormones) sits in a vulnerable part of your skull, so it is often hurt in head injuries, causing major hormonal imbalances.

A Look inside the Skull

A LOOK INSIDE THE SKULL

Looking down from the top, you can see the protective bony ridges, which can damage your soft brain in an accident or injury.

According to the CDC,[305] more than 2 million new head injuries occur in the United States every year. That means over the last 40 years, more than 80 million people have sustained head injuries. And the number of concussions is also rising, especially among children. From 2010 to 2015, concussion diagnoses jumped 43 percent among the general population. For young people from 10 to 19 years of age, however, concussion diagnoses skyrocketed 71 percent.[306] We have to do a much better job of preventing TBIs as well as repairing the brain whenever they occur.

Common causes of head injuries include:

• Falls —falling out of bed, slipping in the bath or shower, falling down steps, or falling off ladders
• Motor vehicle–related collisions —involving cars, motorcycles, or bicycles; also, accidents where pedestrians are involved.
• Violence —caused by gunshot wounds, assaults, domestic violence, or child abuse
• Sports injuries —besides football, they are common in soccer, boxing, baseball, lacrosse, skateboarding, hockey, cycling, basketball, and other high-impact or extreme sports
• Explosive blasts and other combat injuries[307]

At Amen Clinics, we see patients with head injuries from all of these causes. In particular, we have been studying the association between football and brain injuries for several years. When I first started looking at scans, I saw Pop Warner and high school players between the ages of 8 and 18 with clear evidence of TBIs. I was horrified. And then I saw college players whose brains showed even more damage. In the past decade, I’ve met with many active and former NFL players whose scans were even worse. I was heartened when President Barack Obama and LeBron James both said they would not let their children play tackle football. I took it as a sign that this principle is beginning to become part of our cultural fabric. However, this message isn’t hitting the population equally. A 2019 article in the Atlantic reported that white boys in upper-income communities are ditching football for other sports while black boys in lower-income neighborhoods are still flocking to football. In a study of 50,000 students from 8th grade to 12th grade, 44 percent of black boys reported playing tackle football compared with 29 percent of white boys.[308] We need to do a better job of getting the message out to all parents and young people that tackle football and other contact sports can have devastating lasting effects on their lives.

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Tackle football and other contact sports can have devastating lasting effects on your life.

 

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Since 2000, more than 350,000 military veterans have had TBIs.[309] Those injuries mean the Iraq and Afghanistan wars will likely have consequences for the next 70 years because these veterans will have an increased risk for brain health/mental health issues. And as you have seen, the impact of those TBIs will spread beyond the veterans themselves and affect their children and the generations after that. To put an end to this, they need our BRIGHT MINDS approach more than ever and to stand against the cultural norms that dismiss head trauma as a serious issue.

HEAD TRAUMA

THE EVIL RULER WOULD . . .

1. 1. Allow children to hit soccer balls with their heads; play tackle football; ski or ride bicycles without helmets; ride large horses; play hockey; and engage in other high-risk behaviors.
2. 2. Encourage players on a team (especially the better ones) to go back into the game as quickly as possible after suffering a concussion.
3. 3. Put fluorescent lights in all classrooms and workspaces to increase symptoms of anxiety, irritability, depression, or decreased concentration related to Irlen syndrome.

THE BENEVOLENT RULER WOULD . . .

1. 1. Encourage the population to love their brains and the brains of their children and protect them at all costs.
2. 2. Ban children and teenagers from hitting soccer balls with their head or engaging in high-risk activities. Children and teens cannot give informed consent admitting they know and accept the risks of head injuries. Often parents approve of behaviors where they are unaware of the risks.
3. 3. Consider delaying teens getting their driver’s licenses by a year to help cut down on motor vehicle accidents and head injuries.

HEAD INJURY AND MENTAL ILLNESS

Research shows that head injuries increase the risk of:

• Depression[310]
• Anxiety and panic disorders[311]
• Psychosis[312]
• Post-traumatic stress disorder (PTSD)[313]
• Suicide[314]
• Drug and alcohol abuse[315]
• ADD/ADHD[316]
• Learning problems[317]
• Borderline and antisocial personality disorders[318]
• Dementia[319]
• Aggression[320]
• Homelessness[321]
• Victimization[322]
• Loss of or changes in sense of smell or taste[323]

Head trauma may also increase the risk of incarceration.[324] In the United States, 25 to 87 percent of inmates say they have suffered a TBI compared with 10 to 38 percent of the general population.[325] And the latest statistics from the Bureau of Justice Statistics show that 181,500 veterans are incarcerated.[326]

In our database of tens of thousands of patients, 40 percent had a significant brain injury before they came to see us. When people ask me what the single most important lesson I’ve learned from looking at more than 170,000 brain scans is, I reply, “Mild traumatic brain injury is a major cause of psychiatric problems, and very few people know it.”

I hate the terms mild traumatic brain injury and mild concussions because they imply these injuries don’t cause lasting damage, which is often not the case at all. Anyone who has played a contact sport likely has experienced many subconcussive blows, which jostled the brain but did not cause immediate symptoms. The famous boxer Joe Louis (1914–1981) is quoted as saying, “It’s not the big hits that cause dementia, but rather it is the thousands of little hits.”

Head trauma is a major cause of psychiatric illness, and very few people know it because most mental health professionals never look at the brains of their patients, nor do they check the hormones of the brain.

It is important to note that many people forget they’ve had a significant head injury in the past. At Amen Clinics, we routinely ask patients several times whether they have had a head injury. Our intake paperwork asks the question “Have you ever had a head injury?” The historian, who gathers patients’ histories before they see the physician, asks them again about head injuries. The computer testing we have patients complete asks a third time about head injuries. If I see no, no, no as answers, I ask again. If I get a fourth no, I will then say, “Are you sure? Have you ever fallen out of a tree, fallen off a fence, or dived into a shallow pool? Did you play contact sports? Have you ever been in a car accident?”

I’m constantly amazed at how many people think their head injuries were too insignificant to mention. For others, they simply do not remember the incident because amnesia is a common occurrence in head traumas. When asked the question for the fifth time, one patient put his hand on his forehead and said, “Oh, yeah! When I was five years old, I fell out of a second-story window.” Likewise, I have had other patients forget they went through windshields, fell out of moving vehicles, or were knocked unconscious when they fell off their bicycles.

Consider YouTube superstar Logan Paul. The controversial internet personality, who is known for his wild, risk-taking pranks and dangerous stunts, has gained more than 15 million followers. But he has also amassed some harsh critics and was named one of the most hated celebrities of 2018. Some people demanded he be banned from YouTube after he posted an insensitive video of a corpse hanging in a Japanese forest where people go to die by suicide. Logan came to see me to find out why he makes so many bad decisions, why he lacks empathy, and why he is incapable of maintaining a committed relationship. “I want to figure out why I think and act the way I do,” he said in a video about his visit to Amen Clinics. “I’m a bit of a hooligan, a troublemaker.”

As I do with all our patients, I asked him if he had ever experienced head trauma. He told me about a trampoline accident that had fractured his skull when he was in seventh grade. I asked him if there was any other trauma, and he said no. But a few hours later, he revealed something else. Logan shared that he had also been a linebacker and running back on his high school football team. “I was always getting hit in the head,” he admitted. He didn’t think of that as “trauma,” though.

Logan’s brain SPECT scan showed low blood flow and abnormal activity in key areas of his PFC. His history of repetitive head trauma from football combined with the trampoline accident was the main reason behind his bad decisions, lack of empathy, and trouble with relationships.

One of the saddest professional encounters I had was with a mother after I wrote a column on head trauma in the Daily Republic, the local newspaper where I lived in Northern California during the 1990s. A week or so after it appeared, a mother came to see me. She told me that her 20-year-old daughter had killed herself several months earlier, and she was grief stricken over the unbelievable turn of events in her life. “She was the most ideal child a mother could have,” she said. “She did great in school. She was polite, cooperative, and a joy to have around. Then it all changed. Two years ago, she had a bicycle accident. She accidentally hit a branch in the street and was flipped over the handlebars, landing on the left side of her face. She was unconscious when an onlooker got to her, but shortly thereafter she came to. Nothing was the same after that. She was moody, angry, easily set off. She started to complain of ‘bad thoughts’ in her head. I took her to see a therapist, but it didn’t seem to help. One evening, I heard a loud noise out front. She had shot and killed herself on our front lawn.”

Head Trauma Risk Factors
(and the Four Circles They Represent)

1. 1. One or more head injuries

1. 2. Contact sports with concussions

1. 3. Contact sports with subconcussive blows

1. 4. Irlen syndrome

Unrecognized Irlen Syndrome Leads to Mental Illness

Irlen syndrome is a visual processing problem, where certain colors of the light spectrum irritate the brain. It runs in families and is common after TBIs. Anyone experiencing symptoms of anxiety, irritability, depression, or decreased concentration should be screened for it. Common symptoms include

• light sensitivity; being bothered by glare, sunlight, headlights, or streetlights
• strain or fatigue with computer use
• fatigue, headaches, mood changes, restlessness, or an inability to stay focused with bright or fluorescent lights
• trouble reading words that are on white, glossy paper
• words or letters shifting, shaking, blurring, moving, running together, disappearing, or becoming difficult to perceive while reading
• difficulty reading music
• feeling tense, tired, sleepy, or even getting headaches with reading
• problems judging distance and difficulty with such things as escalators, stairs, ball sports, driving, or coordination
• migraine headaches

You can learn more about Irlen syndrome at www.irlen.com.

PRESCRIPTIONS FOR REDUCING YOUR HEAD TRAUMA RISK FACTORS
(AND THE FOUR CIRCLES THEY REPRESENT)

The Strategies

1. 1. Love your brain, and find out if you have had a concussion or head injury (psychological circle because you need to recognize what constitutes head trauma).

   Think back (or ask your mom). Did you ever . . .

   • Fall out of a tree or down stairs?
   • Fall off a horse or roof?
   • Dive into a shallow pool?
   • Fall off a fence head first?
   • Have a car accident (as a driver or passenger)?
   • Have a whiplash accident?
   • Have a work-related head injury?
   • Hit your head on a ball, the ground, or someone else’s helmet in sports?
   • Suffer a concussion playing sports?[327]

1. 2. Avoid any future head injuries by protecting your head. This is worth repeating over and over: Protect your head. It contains your brain, which runs everything in your life. Seems obvious, right?

   Yet we let little children hit soccer balls with their heads and do dangerous gymnastic routines. Explosive new research shows that professional soccer players have a 300 to 500 percent increased risk of dementia.[328] People cheer at high school football games when the opposing quarterback is knocked out of the game with a vicious hit to his head. Many fans love the fights in hockey so much that the NHL has not yet considered eliminating them from the game.[329] I, too, was a crazy football fan. I played football in high school and for fun on weekends; I was a passionate Los Angeles Rams and Washington Redskins fan. The Redskins won the Super Bowl when I lived near Washington, DC, where I was doing my psychiatric residency at the Walter Reed Army Medical Center. Football had been part of my life, and nothing in my medical training caused me to question my devotion to it —until I started to look at the brain and could clearly see the damage it was doing to people’s brains and their lives.

   Only engage in high-risk activities if you don’t care about the rest of your life. Other sports besides football can also be problematic, including hockey, soccer,[330] horseback riding, auto racing, skiing, and others. Wear your seat belt and, as you age, protect yourself from falls, which is one of the greatest risk factors for head injuries.

1. 3. Actively engage in repairing any past head injuries (psychological circle because you need to believe that you can heal your brain). If you have had a head injury, the appropriate treatment can help if you are serious about doing the right things for your brain, providing the support it needs, and attacking all of the BRIGHT MINDS risk factors. I believe the secret to our success with our patients with TBIs is that we use a BRIGHT MINDS approach in all areas, including nutraceuticals. Other treatments include neurofeedback and HBOT, which are detailed below.
   • Neurofeedback: Using your mind to control your physiology for better brain health/mental health. Did you know that you can control your hand temperature, heart rate, and even brain waves with your mind? Or that in doing so, you can reduce the symptoms of TBI, stress, anxiety, depression, and more? Your mind is more powerful than you know. I first began learning about therapies that involve using the mind to control our physiology back in the 1980s.

     In 1987, I took a ten-day training course in a treatment technique called biofeedback that uses technology to measure heart rate, breathing rate, brain wave patterns, hand temperature, sweat gland activity, and muscle tension. The basic concept is simple —once you know your heart rate or breathing patterns, for example, you can learn to use mental exercises and focused attention to control them. You can learn to slow your heart rate, warm your hands, decrease sweat gland activity, and so on.

     That same year, I was assigned to be the chief psychiatrist at Fort Irwin in the Mojave Desert, where army soldiers were training to fight the Russians. Among the soldiers in that isolated desert, there was a high incidence of stress, depression, anxiety disorders, drug abuse, and domestic violence. In an effort to help them, I used biofeedback to help them change their own physiology and reduce their stress. As I taught people about this method, I developed a consistent internal thought in dealing with my patients: “Teach them skills to manage their emotions and mind; don’t just give them pills.”

     As fascinating and helpful as biofeedback was, the part of the training course I took that really changed the trajectory of my psychiatric career was a technique called neurofeedback —also called brainwave or EEG biofeedback. While many psychiatrists at that time still considered the brain to be a “black box,” the professors in this course showed it was possible to look at brain wave signatures and teach patients how to manipulate them. It turned my view of treatment upside down and paved the way for me to become interested in looking at the brain with SPECT scans. It was in that series of lectures that I first got the idea that would become the signature statement of my professional life: “You are not stuck with the brain you have; you can change it! You can change your brain and your life.”

     When I introduced neurofeedback to the soldiers at Fort Irwin, I saw firsthand how it helped them decrease their impulsivity and anxiety and improve their attention, learning, and mood. Now, more than 30 years later, there are more than 1,000 scientific studies showing that neurofeedback can help a wide variety of mental health and brain-related conditions, such as

     • TBI[331]
     • Depression[332]
     • ADD/ADHD[333]
     • Obsessive-compulsive disorder (OCD)[334]
     • Addiction[335]
     • Memory in healthy people[336]
     • Memory post-stroke[337]
     • Epilepsy[338]
     • Pain[339]
     • Balance in Parkinson’s patients[340]

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   Skills, not just pills.

    

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   Brain Wave Basics

   What are brain waves? When masses of neurons communicate with each other, the electrical activity that’s transmitted creates brain waves. The most common brain wave patterns are:

   • delta waves (1–4 cycles per second) —very slow brain waves, seen mostly during sleep; high in TBI and poor memory states
   • theta waves (5–7 cycles per second) —slow brain waves, seen during creativity, daydreaming, and twilight states; higher in ADD/ADHD, impulsivity, poor memory, and brain fog states
   • alpha waves (8–12 cycles per second) —brain waves seen during relaxed states
   • beta waves (13–20 cycles per second) —fast brain waves seen during focused, thinking, analytic states; higher in anxiety states
   • high beta waves (21–40 cycles per second) —fast brain waves seen during intense concentration or anxiety
   • gamma waves (>40 cycles per second) —very fast brain waves, often seen during meditation and creative states

   Neurofeedback is a computer-based interactive therapy that uses video games to help people regulate their brain wave states. For example, at Amen Clinics, patients sit in front of a computer monitor and play a biofeedback game. If they increase the “beta” activity or decrease the “theta” activity, the game continues. However, if the player is unable to maintain the desired brain wave state, the game stops. People find the activity fun, and they gradually learn to achieve a healthier brain wave pattern. Retraining the brain to maintain a more optimal brain wave state takes time, however, and people often require 20 to 60 sessions before being able to recreate the results on their own. Many people find that the benefits are worth it.

   • Hyperbaric oxygen therapy (HBOT) —see chapter 5, “B Is for Blood Flow.”

1. 4. Get your hormones tested, including thyroid, DHEA, and testosterone. Remember that your pituitary gland often gets injured during head trauma. Hormones are often low in people who have sustained head injuries. (For more information, see chapter 13, “N Is for Neurohormone Issues.”)

1. 5. Consider getting a functional imaging study, such as SPECT or QEEG, if you are struggling with your behavior or memory.

1. 6. Take nutraceuticals that are essential to help support the brain’s healing process.
   • Multivitamin/mineral complex —a high dose supplement, with higher doses of vitamins B6, B12, folate, and D for nutrient support.
   • Omega-3 fatty acids —highly concentrated and purified, two grams of total EPA+DHA. Dr. Michael Lewis’s book When Brains Collide details how omega-3 fatty acids can facilitate healing after a concussion and relieve symptoms without medication.[341]
   • A combination of ginkgo (to support blood flow), acetyl-L-carnitine (to support mitochondrial energy), huperzine A (to support acetylcholine), N-acetylcysteine, alpha-lipoic acid (for antioxidant support), and phosphatidylserine (for nerve cell membrane support).

BRIGHT MINDS: HEAD TRAUMA

STEPS TO CREATE MENTAL ILLNESS . . . AND MAKE MY NIECES, ALIZÉ AND AMELIE, SUFFER

1. 1. Deny that brain injuries are likely to cause mental health issues.
2. 2. Engage in habits that increase your risk for head trauma.
   • Play contact sports.
   • Never wear a helmet while skiing, biking, riding a motorcycle, etc.
   • Play soccer and head soccer balls repeatedly.
   • Participate in high-risk adventure activities —free climbing, bungee jumping, etc.
   • Climb trees and ladders and go on the roof.
   • Dive into the ocean or pool without knowing the depth of the water.
   • Don’t wear a seat belt.
   • Drive too fast and text while driving.
   • Text while walking.
   • Don’t practice balance exercises as you age.
3. 3. Avoid the strategies that protect your brain.

STEPS TO END MENTAL ILLNESS . . . AND KEEP MY NIECES, ALIZÉ AND AMELIE, HEALTHY

1. 1. Acknowledge that brain injuries could be causing mental health issues and actively repair past head trauma.
2. 2. Avoid anything that increases your risk for head trauma.
3. 3. Engage regularly in healthy habits that protect your brain.
   • Avoid contact sports.
   • Avoid high-risk activities.
   • Don’t climb trees or ladders or go on the roof.
   • Don’t dive headfirst into any body of water.
   • Always wear a seat belt in the car.
   • Always wear a helmet when skiing or riding a bike.
   • Don’t text while driving or walking.
   • Consider neurofeedback, HBOT, and nutraceuticals.
   • Practice balance exercises, especially as you age.

Pick One BRIGHT MINDS Head Trauma Tiny Habit to Start Today

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1. When I get in the car, I will fasten my seat belt.
2. When I go into the house, I will limit the number of packages I carry at one time to minimize the risk of falling.
3. When I go skiing or biking, I will put on a helmet.
4. When I must go up on the roof, I will make sure it is absolutely safe.
5. When I walk or drive, I will slow down and pay attention to my surroundings.
6. When I walk or drive, I will put my phone out of sight so I cannot text.
7. When I go downstairs, I will hold the handrail.
8. When (and if) I experience a head trauma, I will check my hormones and optimize any that are low.

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[304] Joe Namuth, interview by Howard Stern, “How Joe Namath Reversed His Own Brain Damage Caused by Football,” The Howard Stern Show, June 24, 2019, www.youtube.com/watch?v=s7nxU3QadIA&feature=youtu.be.

[305] “Traumatic Brain Injury and Concussion,” Centers for Disease Control and Prevention, March 3, 2019, www.cdc.gov/traumaticbraininjury/get_the_facts.html.

[306] Blue Cross Blue Shield, “The Health of America Report: The Steep Rise in Concussion Diagnoses in the U.S.,” September 27, 2016, https://www.bcbs.com/the-health-of-america/reports/the-steep-rise-concussion-diagnoses-the-us.

[307] Daniel G. Amen, Memory Rescue (Carol Stream, IL: Tyndale, 2017), 124–25.

[308] Alana Semuels, “The White Flight from Football,” Atlantic, February 1, 2019, www.theatlantic.com/health/archive/2019/02/football-white-flight-racial-divide/581623/.

[309] “DoD Worldwide Numbers for TBI,” Defense and Veterans Brain Injury Center, July 7, 2019, http://dvbic.dcoe.mil/dod-worldwide-numbers-tbi.

[310] A. L. Zaninotto et al., “Updates and Current Perspectives of Psychiatric Assessments after Traumatic Brain Injury: A Systematic Review,” Frontiers in Psychiatry 7 (June 14, 2016): 95.

[311] R. J. Schachar et al., “Mental Health Implications of Traumatic Brain Injury (TBI) in Children and Youth,” Journal of Canadian Academy of Child and Adolescent Psychiatry 24, no. 2, (Fall 2015) : 100–108.

[312] Daryl and Daniel C. Fujii, “Psychotic Disorder Due to Traumatic Brain Injury: Analysis of Case Studies in the Literature,” Journal of Neuropsychiatry and Clinical Neurosciences 24, no. 3 (Summer 2012): 278–89.

[313] G. J. McHugo et al., “The Prevalence of Traumatic Brain Injury among People With Co-Occurring Mental Health and Substance Use Disorders,” Journal of Head Trauma Rehabilitation 32, no. 3 (May/June 2017) : E65–E74.

[314] Jessica L. Mackelprang et al., “Adverse Outcomes among Homeless Adolescents and Young Adults Who Report a History of Traumatic Brain Injury,” American Journal of Public Health 104, no. 10 (October 2014): 1986–92.

[315] Ibid.

[316] Schachar et al., “Mental Health Implications of Traumatic Brain Injury (TBI).”

[317] R. Lajiness-O’Neill et al., “Memory and Learning in Pediatric Traumatic Brain Injury: A Review and Examination of Moderators of Outcome,” Applied Neuropsychology 17, no. 2 (April 2010): 83–92.

[318] G. J. McHugo et al., “The Prevalence of Traumatic Brain Injury among People with Co-Occurring Mental Health and Substance Use Disorders,” Journal of Head Trauma Rehabilitation 32, no. 3 (May/June 2017): E65–E74.

[319] R. C. Gardner et al., “Dementia Risk after Traumatic Brain Injury vs Nonbrain Trauma: The Role of Age and Severity,” JAMA Neurology 17, no. 12 (December 2014): 1490–97.

[320] V. Rao et al., “Aggression after Traumatic Brain Injury: Prevalence and Correlates,” Journal of Neuropsychiatry and Clinical Neurosciences 21, no. 4 (2009): 420–29.

[321] J. Topolovec-Vranic et al., “Traumatic Brain Injury among People Who Are Homeless: A Systematic Review,” BMC Public Health 12 (December 2012): 1059.

[322] Mackelprang, “Adverse Outcomes among Homeless Adolescents,” 1986–92.

[323] P. J. Schechter and R. I. Henkin, “Abnormalities of Taste and Smell after Head Trauma,” Journal of Neurology, Neurosurgery, and Psychiatry 35, no. 7 (1974): 802–10.

[324] “One in Four Prisoners Have Suffered Traumatic Brain Injury, Study Finds,” Glasgow Live, January 18, 2019, www.glasgowlive.co.uk/news/glasgow-news/one-four-prisoners-suffered-traumatic-15695721.

[325] Brian Im et al., “TBI and Incarceration,” American Psychological Association, December 2014, www.apa.org/pi/disability/resources/publications/newsletter/2014/12/incarceration.

[326] Jennifer Bronson et al., “Veterans in Prison and Jail, 2011–2012,” Bureau of Justice Statistics, December 7, 2015, https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5479.

[327] I ask all my patients these questions and referenced them in Memory Rescue, 134.

[328] Daniel F. Mackay et al., “Neurodegenerative Disease Mortality among Former Professional Soccer Players,” New England Journal of Medicine (October 21, 2019), https://doi:10.1056/NEJMoa1908483.

[329] “Fighting in Ice Hockey,” Wikipedia, June 12, 2019, en.wikipedia.org/wiki/Fighting_in_ice_hockey.

[330] H. Ling et al., “Mixed Pathologies Including Chronic Traumatic Encephalopathy Account for Dementia in Retired Association Football (Soccer) Players,” Acta Neuropathologica 133, no. 3 (March 2017): 337–352.

[331] T. Surmeli et al., “Quantitative EEG Neurometric Analysis-Guided Neurofeedback Treatment in Postconcussion Syndrome (PCS): Forty Cases. How Is Neurometric Analysis Important for the Treatment of PCS and as a Biomarker?” Clinical EEG and Neuroscience 48, no. 3 (June 27, 2016): 217–30.

[332] E. J. Cheon et al., “The Efficacy of Neurofeedback in Patients with Major Depressive Disorder: An Open Labeled Prospective Study,” Applied Psychophysiology and Biofeedback 41, no. 1 (March 2016): 103–10.

[333] V. Meisel et al., “Neurofeedback and Standard Pharmacological Intervention in ADHD: A Randomized Controlled Trial with Six-month Follow-up,” Biological Psychology 94, no. 1 (September 2013): 12–21.

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